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Pediatric Pharm Exam 3 > Anxiety and Depression > Flashcards

Anxiety and Depression Flashcards

1
Q

Types of endogenous NTs (4)

A
  1. Serotonin (5-HT)
    * 14 different receptor subtypes
    * found in different parts of the body from brain to gut
  2. Norepinephrine (NE)
  3. Dopamine (DA)
  4. Gamma-aminobutyric acid (GABA)
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2
Q

Other functions of NTs (3)

A
  1. Platelet aggregation and function (5-HT)
  2. Vasoconstriction (DA)
  3. GI signaling (DA and 5-HT) found in GI tract & blood vessels
    * Many side effects will be occur because receptors are scattered throughout the body
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3
Q

Common psychiatric disorders where medications may be useful (11)

A
  1. Anxiety
  2. Attention-deficit anxiety disorder (ADHD)
  3. Autism
  4. Bedwetting
  5. Bipolar disorder
  6. Depression
  7. Eating disorders
  8. Obsessive-compulsive disorder (OCD)
  9. Psychosis
  10. Severe aggression
  11. Sleep disorders
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4
Q

Anxiety signs and symptoms (2)

A
  1. Fear or worry

2. Somatic symptoms (headache, stomach ache)

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5
Q

Common anxiety triggers (4)

A
  1. Social (family, friends, social phobia)
  2. Schoolwork
  3. Major world event or disasters
  4. Medical Procedures
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6
Q

Anxiety Treatments (3)

A
  1. Cognitive behavioral therapy
  2. Psychotherapy
  3. Drugs can used as adjunctive treatment
    - SSRIs
    - Benzodiazepines for acute episodes
    - Propranolol
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7
Q

Alprazolam (Xanax) Onset, Half Life, and Active Metabolite/Metabolism

A

Onset: 60 minutes

Half-Life: ~11 hours

Active Metabolite/Metabolism: Yes/Hepatic

*Remember there are active metabolites for Alprazolam and Diazepam so they will be in the system for much longer if you have hepatic impairment

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8
Q

Clonazepam (Klonopin) Onset, Half Life, and Active Metabolite/Metabolism

A

Onset: 20-40 minutes

Half-Life: 22-33 hours

Active Metabolite/Metabolism: No/hepatic

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9
Q

Diazepam (Valium) Onset, Half Life, and Active Metabolite/Metabolism

A

Onset: 10-20 minutes

Half-Life: Up to 48 hours

Active Metabolite/Metabolism: Yes/hepatic

*Remember there are active metabolites for Alprazolam and Diazepam so they will be in the system for much longer if you have hepatic impairment

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10
Q

Lorazepam (Ativan) Onset, Half Life, and Active Metabolite/Metabolism

A

Onset: 30-60 minutes

Half-Life: ~15 hours

Active Metabolite/Metabolism: No/hepatic

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11
Q

Benzodiazepine Agents, Mechanisms of Action, and Routes

A
  1. Alprazolam (Xanax)
  2. Clonazepam (Klonopin)
  3. Diazepam (Valium)
  4. Lorazepam (Ativan)

Mechanism of action: binds to GABA receptors halting neuronal stimulation

Routes: PO, IV for status epilepticus, IN for emergent use

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12
Q

Benzodiazepine ADEs (5)

A
  1. Respiratory depression
  2. Hypotension, bradycardia
  3. Delirium
  4. Paradoxical agitation
  5. Short term memory loss (can be a benefit)
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13
Q

Cautions/BBWs with Benzodiazepines (2)

A
  1. BBW with opioid use; can cause greater risk of hypotension and respiratory depression
  2. Caution with oral liquid solutions and propylene glycol
    * Caution in use with neonates
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14
Q

Benzodiazepine Metabolism (2)

A
  1. Most undergo hepatic metabolism

2. Drug-drug interactions with CYP450 enzymes; CYP3A4 in particular

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15
Q

Benzodiazepine Elimination (2)

A
  1. All are renally excreted

2. > risk of over sedation and/or prolonged sedation if active metabolites present & renal impairment

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16
Q

Benzodiazepine Recommendations

A

Generally recommended for short-time use; prolonged use causes increased tolerance (more medication needed to do the same effect)
*Withdrawal associated with seizures

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17
Q

Benzodiazepine Place in Therapy (3)

A
  1. Short term use (i.e. PRN)
  2. Not maintenance therapy
  3. Agent of choice depends on duration of use (i.e. short duration versus longer acting)
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18
Q

Benzodiazepine Withdrawal

A

Acute withdrawal following prolonged use is associated with seizures; General taper schedule is 20% every other day until unmeasurable dose or < 0.05 mg/kg per dose

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19
Q

Other Benzodiazepine Uses

A
  1. Nausea/vomiting
  2. Sedation
  3. Acute alcohol withdrawal
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20
Q

Major Depressive Disorder Medications (3)

A
  1. SSRIs/SNRIs
  2. TCAs
  3. MAOIs
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21
Q

Receptor Selectivity: Which drugs are highly selective to SE? (6)

A
  1. Citalopram –> 1.1 selectivity
  2. Escitalopram –> 1.4
  3. Sertaline –> 0.3
  4. Fluvoxamine –> 2.2
  5. Fluoxetine –> 0.8
  6. Duloxetine –> 1.6 (but this drug is more selective to DA)
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22
Q

Receptor Selectivity: Which drugs are highly selective to NE? (3)

A
  1. Desipiramine –> 0.8
  2. Atomaxetine –> 3.5
  3. Nortripytline –> 4.4
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23
Q

Receptor Selectivity: Which drugs are highly selective to DA? (3)

A
  1. Buproprion –> 526 (more than SE and NE)
  2. Duloxetine –> 0
  3. Sertaline –> 25
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24
Q

SSRI vs. SNRI General Considerations (4)

A
  1. Selectivity
  2. Side effect profile
  3. Cost
    * Insurance companies dictate a lot about the drug to choose based on cost
  4. Patient tolerability/effect
    * 20 – 50% will not respond (adult literature)
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25
SSRI Mechanism of Action (4)
1. Binds to SRR preventing serotonin from being taken back into the pre-synaptic cell 2. Increased serotonin in synaptic cleft 3. Increased serotonin binding to post-synaptic receptors 4. Prevent reuptake of 5HT from pre-synaptic cell * Blocking the receptor to increase 5HT levels at the synaptic cleft so that more 5HT can bind to post-synaptic cell and increase signaling
26
SSRI Onset of Action (3 including tapering)
1. Actual beneficial effect can be delayed * Effect typically takes 2 – 4 weeks after starting treatment * Some patients report “feeling better” within a few days 2. Initially starting therapy can increase symptoms * Monitor for increase in harmful or suicidal ideation * BBW: Increased suicidal ideation, especially in adolescents 3. Acutely stopping can lead to abrupt onset of anxiety and depression * Taper off medications is recommended with drugs with shorter half-life (i.e. paroxtine) → especially if they have been on it for a week or more * Longer taper for the longer amount of time they have taken the drug
27
Citalopram (Celexa) PK (substrates and half life)
SSRI 1. CYP3A4, 2C19, 2D6 2. Half life: 35 hours
28
Escitalopram (Lexapro) PK (substrates and half life) | Approved >
SSRI 1. CYP3A4, 2C19 2. Half life: ~30 hours Approved > 12 years
29
Fluoxetine (Prozac) PK (substrates, half life and active metabolite) Approved >
SSRI 1. CYP2CP and 2D6 2. Half life: 4-6 days 3. Active metabolite: half life of 7-9 ayes Approved over 8 years
30
Fluvoxamine PK (substrates and half life)
SSRI 1. CYP1A2 and 2D6 2. Half life: 16 hours * only one approved for pediatric OCD
31
Paroxetine (Paxil) PK (substrates and half life)
SSRI 1. CYP2D6 2. Half life: 24 hours
32
Sertaline (Zoloft) PK (substrate, half life and active metabolite) Approved >
SSRI 1. CYP3A4, 2C19, 2C9, 2D6 2. Half life: 26 hours 3. Active metabolite: half life of 70-80 hours Approved > 6 years
33
Citalopram and Escitalopram ADEs (2)
1. GI distress | 2. Weight gain
34
Fluoxetine and Sertaline ADE
GI distress
35
Paroxetine ADEs (3)
SSRI 1. Sedation 2. GI distress 3. Weight gain
36
Duloxetine and Venlafaxine ADEs (3)
SNRI 1. GI distress 2. Conduct abnormalities 3. Sedation
37
Duloxetine (Cymbalta) available dosage form and PK parameters
SNRI Available dosage form: delayed release capsules PK parameters: 1. Half life - ~12 hours 2. CYP1A2 and CYP2D6 substrate
38
Venlafaxine (Effexor) available dosage form and PK parameters
SNRI 1. Available dosage forms: tablet capsule 2. Half life - depends on dosage form 3. CYP3A4 substrate (does not effect other enzymes)
39
SSRIs/SNRI BBW
Increased risk of suicidal ideation
40
Duloxetine ADEs (6)
SNRI 1. Drowsiness or insomnia 2. Nausea 3. Abdominal pain 4. Constipation 5. Weight gain or loss 6. Headache
41
Venlafaxine ADEs (5)
SNRI 1. Sedation 2. Increased BP 3. GI distress 4. Weight gain or loss 5. Abnormal dreams
42
Desvenlafaxine ADEs (4)
SNRI 1. Increased BP 2. N/V/D 3. Insomnia 4. Decreased appetite
43
SSRI/SNRI General Precautions (6)
1. May take several weeks to see full effect 2. Titrate slowly (every 2-3 weeks) * If one medication does not work when titrated to maximum dose, switch to another medication 3. Use associated with increased risk of suicide * Especially in adolescent age group CAUTION with… 4. Heart rhythm abnormalities 5. Serotonin syndrome 6. Platelet dysfunction
44
Serotonin Syndrome (3)
1. Life-threatening hyperthermia, seizure medical emergency * Or it can cause milder symptoms of tremor, altered mental status, etc. 2. Can be dose-specific or not 3. Increases when used in combination with multiple medications
45
Serotonin syndrome proposed mechanism
Too much 5HT in synaptic cleft causes over-excitation of neuron * Hyperstimulation leading to the side effects * Main concern is hyperthermia
46
Drugs associated with 5HT Syndrome (13)
MUST KNOW FOR EXAM 1. SSRI/SNRIs 2. MAOIs 3. TCAs 4. Lithium 5. Fentanyl 6. Ondansetron 7. granisetran 8. sumitriptan 9. Metoclopramide 10. Linezolid 11. Tryptophan 12. Tramadol 13. Valproatic acid
47
Tricyclic Antidepressants Mechanism of Action
Inhibits the re-uptake of 5-HT and NE increasing synaptic concentrations
48
TCA Agents Available for MDD (4)
1. Doxepin 2. Amitriptyline 3. Imipramine 4. Nortriptyline
49
TCA Pearls (4)
1. May take several weeks to reach full affect * Titrate slowly 2. Due to side effects not routinely used first line especially in pediatrics 3. CAUTION with heart rhythm abnormalities 4. VERY dangerous in overdoses
50
Amitriptyline ADEs (6)
TCA 1. Anti-cholinergic effects ++++ 2. Sedation ++++ 3. Decreased BP +++ 4. Abnormal conduct+++ 5. GI distress + 6. Weight gain ++++
51
Doxepin ADEs (5)
TCA 1. Anticholinergic effects +++ 2. Sedation ++++ 3. Decreased BP ++ 4. Abnormal conduct ++ 5. Weight gain ++++
52
Imipramine ADEs (6)
TCA 1. Anticholinergic effects +++ 2. Sedation +++ 3. Decreased BP ++++ 4. Abnormal conduct +++ 5. GI distress + 6. Weight gain ++++
53
Nortriptyline ADEs (5)
TCA 1. Anticholinergic effects ++ 2. Sedation ++ 3. Decreased BP + 4. Abnormal conduct ++ 5. Weight gain +
54
Dopamine Reuptake Blockers MOA (4)
1. Structurally different than all other antidepressants 2. MOA not fully understood 3. Dopaminergic and noradrenergic activity 4. Weak inhibitor of dopamine and norepinephrine * No inhibition of serotonin * Won’t see anticholinergic/BP side effects
55
DA Reuptake Blocker Agent
Buproprion (Wellbutrin)
56
Buproprion ADEs (2)
1. Abnormal Conduct | 2. GI distress
57
Buproprion Place in therapy (1) and useful for (3)
Place in therapy: 1, Depression refractory to SSRIs/SNRIs Useful for 1. Older patients with ADD/ADHD 2. Older patients with SAD 3. Smoking cessation
58
Noradrenergic Antagonists MOA
1. Tetracyclic antidepressant 2. Increases release of norepinephrine and serotonin * Does not inhibit reuptake
59
Noradrenergic Antagonist Agent
Mirtazapine (Remeron)
60
Mirtazapine (Remeron) ADEs (5)
1. Anticholinergic effects + 2. Sedation +++ 3. Decreased BP + 4. Conduct abnormal + 5. Weight gain +++
61
Mirtazapine (Remeron) Place in therapy
Depression refractory to SSRIs/SNRIs
62
Mirtazapine (Remeron) Contraindications
Contraindicated with MAOIs or linezolid | *Requires 14 day ‘wash out’

Pediatric Pharm Exam 3 (11 decks)

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